Papers
"There are many “Root Cause Analysis” methods, procedures, and approaches on the market today. None of these methods define “root causes.” They say they do, but they do not. No-one can agree on what a “root cause” is, and yet most people say they’re defining “root causes.” Saying it differently, everyone says they do “Root Cause Analysis” these days, and yet everyone is doing something different. Think about it…"
"Our phone rings when something catastrophic occurs. Someone, in their organization or community, experiences a failure that stops them from continuing in the normal routine of life. They need an independent investigator to lead the effort to learn what happened and understand it to an extent that we can move forward with a high level of confidence that it won’t be repeated. Before I get off the phone, I already know what we're going to find, small unresolved problems."
"Try taking notice of the damage being caused by our human tendency to “blame one another.” Notice what happens when something goes wrong in your life, either at home, within your community, or at work. Listen to what people say, and observe how they behave. More importantly ...."
"Does your organization prefer to end its inquiries with system-type “causes?” If so, you will end-up wrapping yourselves into a tighter and tighter ball of checklists, procedures, and other rigid controls that are impossible for people to dwell in. Please do not go down this path. Learn from those who have. It is a dead-end, and often a fatal one."